John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Alongside the thousands of Cochrane Reviews of the effects of treatments, are some that look at the effectiveness of different ways of organising and paying for health care. In a new Cochrane review from August 2016, Charles Wiysonge from the Cochrane South Africa at the South African Medical Research Council in South Africa and colleagues examined the evidence for public stewardship of private for-profit healthcare providers in low- and middle-income countries. He tells us what they found in this podcast.

Charles: Private healthcare providers play a major role in providing healthcare services in settings where the public sector does not provide high quality services. However, the health care that the private sector provides is not always of high quality, which is sometimes because recommended practices and guidelines are not always followed by the private for- profit health sector. Therefore, governments should ensure that the private health sector follow a certain quality, and public stewardship is one way for them to do this. There are various types of public stewardship and we focused on three namely training, regulation and coordination.
Regulation refers to the setting and enforcement of quality standards; training involves educating and supporting private for-profit service providers; and co-ordination entails organising and creating referral systems between private for-profit and public sector healthcare providers.
We investigated the effects of these three methods in low- and middle-income countries by reviewing the evidence on public sector efforts to work with private for-profit health service providers to improve the quality of existing healthcare services. We also wanted to look at secondary outcome like equity, cost implications, mortality, morbidity, and adverse effects; but only the main outcome was reported in all the studies.
We included six studies that targeted private for-profit pharmacy workers in Africa and Asia. Two of these assessed training alone; one assessed regulation alone; three assessed a multifaceted intervention involving training and regulation; but none assessed coordination.
Starting with training: in studies from Kenya and Indonesia, the Ministry of Health offered private drug sellers short training sessions on prescribing and dispensing drugs. These sellers were compared to drug sellers who were not offered training and the findings suggested that training probably improves the quality of healthcare services.
On regulation: in a study in the Lao People’s Democratic Republic, the Ministry of Health supervised private pharmacy services in certain districts over a three-month period, applying sanctions when rules were broken, and offering information about areas needing improvement. When these districts were compared to districts without this enhanced supervision, little or no difference was found in quality of care.
Finally, when training and regulation interventions were combined; three studies in Vietnam and Thailand tested whether private pharmacies that received educational visits as well as visits from pharmacy inspectors to enforce regulations delivered better quality care than pharmacies in districts that did not receive any such visits. The research suggested that these types of visits may improve quality of care.
In summary, although the results for some interventions are promising, rigorous impact evaluations are still needed to answer important questions about the effects of these interventions. These studies need to assess outcomes beyond quality of care, including impacts on equity, cost implications, mortality, morbidity, and adverse effects.

John: Details about the existing research, and the public stewardship interventions that have been tested are available in the full Cochrane Review, which is available free to view at Cochrane Library dot com, with a simple search for ‘public stewardship’. That’s also the place to find future updates of the review should these new impact evaluations get done.